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From a physiologic standpoint human aging is characterized by progressive constriction of
the homeostatic reserve of every organ system
HOMEOSTENOSIS
Principles of geriatric medicine
• Individuals become more dissimilar as they age.
• An abrupt decline in any system or function is always due to disease and not to “normal aging”.
• Normal aging can be attenuated by modification of risk factors.
• Healthy old age is not an oxymoron
Other Concepts
• Disease presentation is of ten atypical in the elderly.
• Because of decreased physiologic reserve, older patients often develop symptoms at an earlier stage of their disease.
• Since many homeostatic mechanisms may be compromised concurrently,there are usually multiple abnormalities amenable to treatment.
• Many findings that are abnormal in younger patients are relatively common in older people.
• Because symptoms in older people are often due to multiple causes,the diagnostic “law of parsimony” often does not apply.
• Because the older patient is more likely to suffer the adverse consequences of disease, treatment __ and even prevention__ may be equally or even more effective.
EPIDEMIOLOGY
• The population 65 years and older has grown from 20 million in 1970 to
35 million in 2000 and there will be 69 million by 2030
• At present 1 in every ten people is 60 years or older. By 2050 this is projected to become 1 in every 5.
• The number of 100 years and older is projected to increase from 145000 in 1999 to 2.2 million by2050
• In this older population cardiovascular disease plays a significant role and is the most common cause of morbidity and mortality.
• The overall cost of treating cardiac disease in people older than the age of 65 years was estimated at $58 billion in 1995.
SYSTEMIC HYPERTENSION IN THE ELDERLY prevalence and incidence
• - BP>140/90 occurs in half to two thirds of people older than 65y and in 75% of people older than 80y.
• - Systolic hypertension becomes more prevalent with aging.
• - “Isolated” systolic hypertension, without elevation of diastolic blood pressure, is present in about 8 percent of sexagenarians and more than 25 percent of the population older than 80 years of age.
TREATMENT
• - The need for treatment of hypertension in the elderly.
• - There is cardiovascular benefit for treatment of systolic or diastolic blood pressure in the elderly.
• - Combination of drug regimens including a diuretic are usually required to approach blood pressure targets.
• - Different combination of pharmacological agents
may have advantages based on the patients,
concomitant diseases, genetics, or risk factors.
• - Dihydropyridine calcium channel blockers greater stroke benefit.
• - ACE inhibitors cardiac benefit, primarily in
men.
• NSAIDS, as well as cox-2 selective NSAIDS.
• Thiazide diuretics.
• - Lower initial drug dosages and slower medication titration, as well as the need for monitor for postural hypotension.
• - Postural hypotension of greater than 20 mmHg or 20 percent of systolic pressure is a risk factor for falls and fractures that carries significant morbidity and mortality.
• - Diuretic therapy.
• - Postprandial decline in both systolic and diastolic blood pressure.